Improving Renal Tumor Biopsy Prognostication With BAP1 Analyses

Context.—Active surveillance of small renal masses highlights the need for accurate prognostication of biopsies. Objective.—To comprehensively evaluate the accuracy of biopsies in assessing known prognostic parameters including histologic subtype by comparison with subsequent nephrectomy samples. Design.—We retrospectively identified patients at University of Texas Southwestern Medical Center, Dallas, Texas, who had a biopsy for a renal mass between 2004–2018. Biopsy samples were evaluated for known prognostic factors such as tumor grade, necrosis, sarcomatoid/ rhabdoid change, and BRCA1-associated protein-1 (BAP1) status, which we previously showed is an independent prognostic factor for clear cell renal cell carcinoma. Accuracy was determined by comparison with subsequent analyses of nephrectomy specimens. Statistical analyses were performed to assess biopsy accuracy and correlation with tumor size and pathologic stage. Results.—From 805 biopsies with a diagnosis of renal neoplasm, 178 had subsequent resection of the biopsied tumor. Concordance rate for histologic subtype was 96.9% (j [w], 0.90; 95% CI, 0.82–0.99) and excellent for small renal masses (98.8%; j [w], 0.97; 95% CI, 0.90–1). Amongst the prognostic variables evaluated, BAP1 immunohistochemistry in clear cell renal cell carcinoma had the highest agreement (94.8%; j [w], 0.83; 95% CI, 0.66–0.99). The presence of 1 or more aggressive features (grade 3–4, tumor necrosis, BAP1 loss, sarcomatoid/rhabdoid change) in a biopsy significantly correlated with pT stage (P ¼ .004). Conclusions.—Biopsy analyses showed high accuracy for subtyping renal tumors, but it underestimated several poor prognostic features. Addition of BAP1 for clear cell renal cell carcinoma may increase prognostic accuracy. If validated, routine incorporation of BAP1 immunohistochemistry in clear cell renal cell carcinoma biopsies may refine prognosis and aid in the selection of patients for active surveillance.